Moving In and Out

Moving In and Out

Head down, he cried softly, “I can’t believe I’ll never see him again, never have the chance to talk with him about us, never try to resolve all the pain in our relationship.”

Then he fell silent and moments passed. I knew, of course, about his father’s recent death and their stormy relationship. I was moved by his sadness—could feel it within. I found myself thinking about my own father’s death. The silence between us continued, and finally I said, “It is so sad.” His crying intensified; he did not look at me. I felt a teary mist in my eyes and thought, “Now what?” Should I try to stay inside where he was and reflect again on his sadness, or should I back away by offering him a more cognitive level of dialogue? This question—whether to move in or out or, perhaps more accurately, to offer him the choice of where he feels most safe—is at the heart of some forms of psychotherapy. However, as we shall see, this is not the case in all forms.

Some of the factors that influence the psychotherapist’s ability to move back and forth between intimacy and detachment will be explored in this essay. My focus will be on only 3 of these factors: the psychotherapist’s theoretical orientation, some aspects of his or her personality, and whether residency training (or other educational pursuits) encourages the development of this ability.

Although under ideal circumstances a psychotherapist might be able to use different theoretical stances according to what seems best suited to the patient and his dilemma, that has, in my experience, rarely been the case. Even in my genera­-tion, with its psychotherapeutic emphasis, residency training was almost entirely psychoanalytic in its orientation. One was taught only psychoanalytic psychotherapy. Somewhat later, Havens,1 more than anyone else, wrote about the different schools of psychiatry (objective-descriptive, psychoanalytic, interpersonal, and existential) and the psychotherapeutic interventions that flowed from each theory.

The movement in the psychotherapist’s mind from detachment to empathy and back to detachment is central to my understanding of psychoanalytic psychotherapy. Other forms of current psychotherapies take different stances. Existential therapies usually call for a radical empathic stance (“being and staying”), and detachment is considered an interruption or defeat of the psychotherapeutic process. At the other extreme are those therapies in which detachment is the therapist’s optimal mental state. In cognitive therapies, for example, the therapist examines with the patient the nature of the patient’s cognitions. There is no central theoretical mandate for empathic relatedness, although the therapist may be a deeply empathic person. However simplified these brief descriptions of existential and cognitive therapies are, the lesson is that the movement back and forth between detachment and empathy is much more a central feature of some psychotherapeutic orientations than it is of others.

There is, however, a serious qualification to this line of thinking. Most psychotherapists are not purists in the sense that their work with patients flows seamlessly from a single theory of the mind. Rather, they patch together a quilt of premises from different theories that is congenial with their personality makeup. It may or may not emphasize the importance of both detachment and empathy.